Signature of Patient* Date/Time

FLORIDA DEPARTMENT OF CORRECTIONS
REFUSAL OF HEALTH CARE SERVICES
This is to certify that I am refusing the following:
Medical Services
Mental Health Services
Dental Services
Medication
Lab/Diagnostic testing
Other
I understand this refusal is against the advice of my health care providers. I acknowledge that I have been informed of the
diagnosis, if known, the nature and purposes of the proposed procedure/treatment/medication, risks and benefits of the
proposed procedure/treatment/medication, alternative treatments and their risks and benefits and the consequences and
danger to my health and possibly to my life that may result from my refusal of this procedure/treatment/medication.
I have been given time to ask questions about my condition and about my decision to refuse the proposed
procedure/treatment/medication that my health care provider has explained to me is medically indicated and necessary.
I voluntarily assume the risks and accept the consequences of my refusal of the procedure/treatment/medication and I am
releasing the Department of Corrections, all health care providers, the facility, and facility staff from any and all liability
for ill effects that may result from my refusal of treatment.
Signature of Patient*
Date/Time
Two Witnesses: I,
patient voluntarily sign this form/refuse to sign the form.
Signature of Witness
am a health care staff member and I have witnessed the
Title of Witness
I,
am a staff member who is not the patient’s health care
provider for this procedure and I have witnessed the patient voluntarily sign this form/refuse to sign the form.
Signature of Witness
Title of Witness
I, the below-signed physician, am aware that this patient refused the proposed procedure/ treatment/medication and has
signed this form/ refused to sign the form.
Signature of Clinician
Date/Stamp
Interpreter/translator: To the best of my knowledge, the patient understood what was interpreted/translated and
voluntarily signed this form/refused to sign the form.
Signature of Interpreter/Translator
Title of Witness
*If the patient refuses to sign this document, but has verbally refused the above procedure, write REFUSES TO SIGN above Signature of Patient.
Inmate Name
DC#
Date of Birth
Race/Sex
Institution
__
DC4-711A (Effective 11/28/10) (Page 1 of 2)
Incorporated by Reference in Rule 33-401.105, F.A.C.
ESTADO DE LA FLORIDA DEPARTAMENTO DE CORRECCIONES
DECLARACION JURADA DE RECHAZO A TRATAMIENTO MEDICO
Yo certifico que rechazo lo siguiente:
Servicios medicos
Servicios de salud mental
Servicios dentales
Medicamentos
Examenes de laboratorio/dignostico
Otros
Yo comprendo que este rechazo es en contra de la opinion medica. Yo reconosco que he sido informado del diagnostico,
si es confirmado, la condicion y proposito del tratamiento o intervencion/ medicamento, consecuencias, los beneficios del
tratamiento ntervencion recomemdada/ medicamento, tratamiento alterno, consequencias y peligros para mi salud y
posible riesgos de muerte que puede resultar por no consentir a estos servicos de atencion medica.
Se me ha dado suficiente tiempo para hacer preguntas, consecuencias, los beneficios del tratamiento/ intervencion
recomemdada, se me ha explicado la naturaleza de mi affeccion y he sido informado del riesgo para mi salud. Se me ha
explicado y entiendo la necesidad de atencion medica, que es indicada y necesaria.
Yo voluntariamente asumo los riesgos y acepto las consecuencias de mi rechazo a tratamiento medico/ medicamento. Yo
declaro, que el medico que me atendio, la institucion, el personal administrativo y el Departamento de Correcciones no
son responsables por cualquier incapacidad, complicaciones que puedan ocurrir como consecuencia de haberme negado a
recibir tratamiento medico.
Firma del Paciente*
Fecha/Hora
Dos Testigos:
Yo,
soy un miembro del equipo medico y he sido testigo que el
paciente ha firmado voluntariament este documento/rehusa firmar.
Firma del testigo
Titulo del testigo
Yo, _____________________________ soy miembro del equipo medico que no es el proveedor del
cuidado de salud del paciente para este procedimiento y he sido testigo que el paciente voluntariamente firmo este
documento / rehuso firmar el documento.
Firma del testigo
Titulo del testigo
Yo, el medico abajo firmante, me enterado que este paciente rehusa el proposito del tratramiento o
intervencion/medicamento y a firmado este documento/rehusa firmar.
Firma del Medico
Fecha/Sello
*Si el paciente rehusa firmar este documento, pero verbalmente rechaza el procedimiento arriba descrito, escriba REHUSA FIRMAR ARRIBA Firma del Paciente.
Inmate Name
DC#
Date of Birth
Race/Sex
Institution
DC4-711A (Effective 11/28/10) (Page 2 of 2)
Incorporated by Reference in Rule 33-401.105, F.A.C.